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Strength: Very Weak

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* Phone Number

* Date of Birth (MM/DD/YYYY) For example, December 25, 2021 is 12/25/2021

Race / Ethnicity - Please provide us with this information so that we can manage your care. Some drugs may have variable effects in different racial/ethnic groups.

* Biological Gender

Male

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* Are you currently pregnant?

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If YES, when is your due date? (MM/DD/YYYY) For example, December 25, 2021 is 12/25/2021

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If YES, please list all allergies below:

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By checking the box above, I am indicating that I agree to the Privacy Policy and Terms of Use of the Pill Pals website. In addition, I have read the Electronic Signature Consent Statement, HIPAA Authorization & Disclosure, and Disclaimer pages.

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